Poisoning –

the pharmacists’

perspective

Shyamala Nara MScClinPharm

Pharmacy Practice Manager

Singapore General Hospital

What’s new in this edition?

CPG format provides info on levels of evidence & grades of

recommendations, which were not present in the 2/2000

edition.

Pharmacists can & should facilitate the implementation of

evidence-based CPG guidances when drug overdose

situations are encountered, esp in healthcare settings.

New section on Bites & Stings

Selected classes of medicines

Really useful annexes!

What can a pharmacist do?

1. Apply expert knowledge of pharmacology & medication use

behaviours

2. Conduct education

3. Perform epidemiologic surveillance

4. Support disaster planning

5. Manage antidote inventory & usage

6. Participate in clinical toxicology services

7. Run a drug & poisons information centre

Pharmacist Louis Gdalman of Chicago developed a hospital-based program of

poison information and consultation in the 1940s and 1950s that later became the

model for the first poison control center (1953).

Our training is useful in drug OD situations :

Strong background in PK/PD of medications

Knowledge of dosage forms and pharmaceutics to predict toxicokinetic

pathways

Identify ADRs, drug interactions, and other drug-related problems whose

symptoms mimic as drug overdose

Recommend treatment, including choice & dosing of antidotes

Trained to conduct literature reviews and apply EBM principles

Conduct poison prevention at patient level e.g. multiple paracetamol-

containing products, drug use by children & elderly, storage of medicines, etc

Talk to patients about herbal meds (contaminated with adulterants)

Identify and advise on non-toxic exposures to common household products

Prevent Rx drug abuse e.g. salbutamol tab, cough mixtures

1. Expert knowledge of pharmacology

& medication use behaviours

Pharmacists are constantly challenged to ensure the safe use

of medications and, by doing so, to avoid potential toxicity.

Pharmacists provide education programmes for

Professionals & the Public

• Organise Poison Prevention Week activities (including

seminars, posters, leaflets, & peripherals)

• Ongoing public outreach (schools, libraries, companies)

• Training of interns/fellows

• Education during dispensing

2. Conduct Education

Basic clinical toxicology should be taught to

pharmacy undergraduates, and reinforced to

those who work in a hospital pharmacy setting.

Records of poisoning cases : analysis and datamining

Detect trends

Plan preventive programmes

e.g. multiple paracetamol syr concentration (infant vs. children) 160 mg/5ml product now in US drugstores to replace older conc infant drops (80 mg/ml).

Consumer advisory posted by US FDA on 22/12/11 at www.fda.gov/ForConsumers/ConsumerUpdates/ucm284563.htm

e.g. stonefish envenomation Trend detected at DPIC. Database review and DEM records (2004-2006).

30 cases were identified. Median age 28 years, 80% male, and 47% foreign nationals.

Most incidences occurred on weekends/public holidays (77%), with November having the highest number of cases (n=7). The majority of cases (80%) arrived at the hospital within two hours of envenomation. Symptoms included extreme pain, swelling and redness of the affected limbs.

Treatment = 24 (80%) patients received hot water soak treatment and 27 (90%) patients received either intramuscular pethidine or diclofenac for analgesia, where nine patients (33%) required additional analgesics after a period of observation.

Outcome = 17 patients (58%) were treated and discharged, eight (26%) were referred to a specialist for follow-up, and five (16%) were admitted for an average of three days. 13 out of 25 patients (52%) were discharged with antibiotics. One case complained of persistent pain and hyperalgesia five months post-envenomation. One patient required surgical intervention. No deaths and systemic symptoms were reported.

Stonefish envenomation, though it rarely kills, can cause extreme pain, swelling and erythema, which can be managed with symptomatic treatment.

Refce: Ngo SY, Ong SH, Ponampalam R. Stonefish envenomation presenting to a Singapore hospital. Singapore Med J 2009 May; 50(5): 506-9.

3. Perform epidemiologic surveillance

Pharmacist role in emergency preparedness in PIC context e.g. chemical spills, HAZMAT or biological warfare.

Planning and preparedness

Nerve centre for disaster mgmt

Support police & SCDF

Dissemination of clinical toxicology information to professionals, and advisories to the public during crisis though website / hotline

e.g. chlorine gas poisoning in Singapore

Incident at local swimming pool. Patients (n=54) sought treatment in 2 EDs , HAZMAT disaster plan was activated..

Patients were decontaminated at shower facilities prior to entering the ED. The ED was reorganized to cope with existing patients, as well as large influx of patients from event site.

Protocol established in coordination with the local drug and poison information center to manage the patients who suffered from chlorine inhalation.

Injuries = Acute respiratory symptoms were the most common symptoms., Four children and four adults were admitted to the hospital, and the other patients were discharged from the ED after observation. All of the chest x-rays were normal on the day of the chlorine inhalation.

Outcomes = Most patients were observed in the ED and subsequently discharged. Outpatient review appointments were scheduled. There were no mortalities or significant morbidities, even up to six months after the incident.

No severe injuries and limited number of admissions, some valuable lessons were learned. Refce : Ngo A, Ponampalam R, Leong M, Han LS. Chlorine and its impact on an emergency department. Prehosp Disaster Med 2007;22(2):136-9

4. Disaster planning

List of antidotes & emergency meds is, maintained by

pharmacists

5. Antidotes

Pharmacists role :

Take advice of TAT and other govmt bodies, Medical Boards

Emergency stockpile inventory mgmt

Source for range of obscure antidotes

Advise on clinical prescription & administration

SGH Emergency Stockpile – via DEM referral

ABSOLUTE ALCOHOL 95% INJ (20ML)

ACETYLCYSTEINE 2g/10ml INJ

ACTILYSE 50mg(RTPA) INJ

ACTIVATED CHARCOAL SUSPENSION 50g

ATROPINE SULPHATE 12mg/2ml INJ

BENTONITE SUSPENSION 7% (300ml)

CALCIUM DISODIUM EDETATE 200mg/ml INJ

CALCIUM GLUCONATE GEL 2.5%

CALCIUM LEUCOVORIN INJ (FOLINIC ACID 50mg/5ml)

CYANIDE ANTIDOTE SOLN A&B

DANTROLENE SODIUM 20mg INJ

DESFERRIOXAMINE 500mg DESFERAL) INJ

DIGIBIND 40mg INJ

DIMERCAPROL 100mg/2ml (BAL) INJ

DIPHENHYDRAMINE 50mg INJ

DIPTHERIA ANTITOXIN 10,000 units INJ

ETHANOL 95% (ORAL) 200ml

FACTOR IX 500u/vial INJ

FACTOR VIII 250u/vial INJ

FLUMAZENIL 0.5mg/5ml INJ

GLUCAGON 1mg INJ

HEPATITIS B IMMUNE GLOBULIN 0.5ml INJ

HEPATITIS B IMMUNE GLOBULIN 5ml INJ

HUMAN ANTI-RABIES IMMUNOGLOBULIN INJ

HUMAN ANTI-TETANUS IMMUNOGLOBULIN 250u INJ

L-THYROXINE(T4) 200mcg INJ

METHYLENE BLUE 1% INJ 5ml

NALOXONE 0.4mg/ml INJ

PAM (PRALIDOXIME) 500mg/20ml INJ

PHOSPHATE BUFFERS

PHYSOSTIGMINE 2mg/2ml INJ

POLYVALENT ANTI-SNAKE VENOM SERUM

PROTAMINE SULPHATE 50mg/5ml INJ

RABIES VACCINE (INACTIVATED) 2.5u/vial

SEA SNAKE ANTIVENOM INJ

SODIUM NITRITE 3%w/v 10ml INJ

SODIUM THIOSULPHATE 25% INJ 20ml

SODIUM THIOSULPHATE 50gm powder

VARICELLA ZOSTER IMMUNOGLOBULIN INJ

Pharmacists in Singapore are increasingly involved in clinical patient care.

* ED pharmacists are new-ish phenomenon in US. Locally, SGH is in planning stages for this role.

What extra can a pharmacist do in the field of toxicology?

• DEM } Identification of meds/substances

• Hospital Inpatient } Develop & implement protocols

• Outpatient } Educate staff

• Consultant to analytical toxicology laboratories

• Expert witness in legal proceedings

• Safety office of pharmaceutical/chemical industry

6. Clinical toxicology pharmacist

Rajendran SD, Kaleemuddin M, Bhojraj S. The role of the clinical pharmacist in poison-related admissions in a secondary care hospital. Aust J Hosp Pharm 2001 Mar; 31(1).

Clinical pharmacist involvement improved the identification of poisons and treatment protocols for poisoning. The program could have contributed to reduced fatalities and improved therapeutic outcomes for survivors.

Chyka PA. Pharmacists as Clinical Toxicologists: Reflections on Evolution, Challenges, and Opportunities. Ann Pharmacother 2007 Oct; 41(10): 1708-2711.

pharmacist-based toxicology consultation provided since 1971

In two-thirds of the US’ 61 poison control centers, pharmacists with clinical toxicology board certification fulfill one or more leadership positions

Certified Specialists in Poison Information (CSPI), or Diplomates of the American Board of Applied Toxicology (DABAT).

6. Clinical toxicology pharmacist

“When we need it, we need it” : a PIC is critical in cases

of emergency. However the number of drug OD and

poisonings in SG is currently low.

Combined 24/7 DPIC provides better value for money

than separate poisons info & drug info hotlines.

Patients’ need for independent unbiased medicines

information is high, but no such service exists in

Singapore.

Can still contact the various RH’s drug info svces for

information, but in emergency pls send pt to A&E or

consult toxicologist.

7. Who you gonna call?

Preventing Accidental

Poisonings in Children Safe Practice Recommendations

All health care practitioners and caregivers play a role in preventing accidental poisonings in children. Take time to educate your patients about strategies to reduce the risk of accidental poisonings by reviewing the following information:

Keep all meds, including OTC & herbal products, locked in a cabinet or drawer out of the reach and sight of children.

Never leave medications (including children’s vitamins or iron supplements) on counters or tables, even if they are in child-resistant containers.

Avoid keeping medications in purses, backpacks, or suitcases where children may explore.

When children visit other residences, look for potential poisoning dangers and intervene before an accident happens.

Do not take meds in front of children, because they tend to mimic what adults do.

Never refer to medication as candy.

Be cautious when medications are out on the counter ready to be used, as many poisonings occur when an adult becomes distracted while taking the medication.

Use child-resistant caps or containers and be sure they are closed properly after use. Remember that “child resistant” does not mean “child proof.”

Stay calm and get help immediately if accidental poisoning is suspected.

Visit www.poisonprevention.org to find out how to prevent unintentional poisonings.

Poison Prevention for Adults Poison proof the home

1. Plants

2. Chemicals

3. Medication

Doctors = PLEASE practice medication safety by giving clear advice on storing & using medication, especially in older adults. Provide written information, as well as a medication list.

Teach patients to understand medication labels

Reading the label will tell you:

What the medicine is for (indications)

How to take the medicine (directions)

What is in the medicine (contents, or active and inactive ingredients)

What the unusual effects are (warnings)

What activities you should not do while taking the drug (precautions)

Poison Prevention for Adults Safe Practice Recommendations

Prescription drugs

Make sure you have the correct medicines and they are clearly labeled. Follow the label's instructions, including dosage. Some medicines are to be taken at different times, so make sure to review the instructions every time you take it. Look for capsules or tablets that differ from others in the container.

Review all your medicines (including food supplements such as vitamins, minerals, or herbs) with your doctor or pharmacist at least once a year or when you start taking a new drug.

Never take medicine in the dark. Turn on a light and make sure you take the right medicine and right dose described on the label. If you need glasses to read, wear them when taking medicine.

Never take other people's prescription drugs. Take only drugs that are prescribed for you.

Over-the-counter drugs

Know what types of over-the-counter drugs to avoid taking with your prescription drugs. When in doubt, ask your pharmacist or doctor before using an over-the-counter drug.

Common over-the-counter drugs that can cause problems when taken with other drugs include pain medicine, laxatives, cold medicines, and antacids.

Compare the active ingredients in medicines before taking two over-the-counter drugs together. Many drugs contain the same active ingredient. You can easily take more than is safe without knowing it.

Get rid of medicines that have expired or are no longer needed. Ask your local pharmacist how you can return unused, unneeded, or expired prescription drugs to pharmaceutical take-back locations or you local poison center for safe disposal.

Thank You